Covid 19 Staff Screening

Name *

Date *

Do you have any of the following symptoms? *

Fever and/or chills

Cough and/or barking cough

Shortness of breath

Headache that is unusual or long lasting

Conjunctivitis (pink eye)

A decrease or lack of apetite

Decrease or loss of taste and/or smell

Sore throat or trouble swallowing

Abdominal pain that is persistent or ongoing (not realted to known causes or conditions e.g., menstrual cramps, gastresophageal reflux disease

For adults (18 years of age or older): Tiredness, muscle aches or joint pain OR For children (under 18 years of age): Nausea, vomiting and/or diarrhea

None of the above

Does anyone in your immediate household have any of the above symptoms?

Yes

No

Exposure History (check all that apply): *

Have you or someone you live with travelled outside of Canada AND been advised to quarantine (as per federal quarantine requirements)?

Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (staying at home)?

In the last 5 days, have you been identified as a “close contact” of someone who currently has COVID-19?

In the last 5 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?

In the last 5 days, have you received a COVID Alert exposure notification on your cell phone?

In the last 5 days, has someone you live with been identified as a “close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate?

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?

None of the above

If you have checked any boxes other than “none of the above” or, if you have checked "yes", do not enter the workplace and notify your supervisor. Go home, self-isolate, follow public health guidelines, and keep your supervisor up to date on your status.

Additional Information (use if needed):

Accuracy of Information *

I certify that the information provided above is accurate at this current time

Collection of Information *

I understand that information collected will be kept confidential and only used for contact tracing purposes.

Signature *

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COVID 19 Staff Screening tool